Beliefs and expectations of rural hospital practitioners towards a developing trauma system: A qualitative case study

BackgroundAn understanding of stakeholders’ views is key to the successful development and operation of a rural trauma system. Scotland, which has large remote and rural areas, is currently implementing a national trauma system. The aim of this study was to identify key barriers and enablers to the development of an effective trauma system from the perspective of rural healthcare professionals.MethodsThis is a qualitative study, which was conducted in rural general hospitals (RGH) in Scotland, from April to June 2017. We used an opportunistic sampling strategy to include hospital providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and transcribed. Thematic analysis was used to identify and group participant perspectives on key barriers and enablers to the development of the new trauma system.ResultsWe conducted 15 interviews with 18 participants in six RGHs. Study participants described barriers and enablers across three themes: 1) quality of care, 2) interfaces within the system and 3) interfaces with the wider healthcare system. For quality of care, enablers included confidence in basic trauma management, whilst a perceived lack of change from current management was seen as a barrier. The theme of interfaces within the system identified good interaction with other services and a single point of contact for referral as enablers. Perceived barriers included challenges in referring to tertiary care. The final theme of interfaces with the wider healthcare system included an improved transport system, increased audit resource and coordinated clinical training as enablers. Perceived barriers included a rural staffing crisis and problematic patient transfer to further care.ConclusionsThis study provides insight into rural professionals’ perceptions regarding the implementation of a trauma system in rural Scotland. Barriers included practical issues, such as retrieval, transfer and referral processes. Importantly, there is a degree of uncertainty, discontent and disengagement towards trauma system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and the effective delivery of rural trauma systems.     

The improved oval forceps suture-guiding method for minimally invasive Achilles tendon repair

ObjectiveTo discuss the effect and advantage of the improved oval forceps suture-guiding method combined with anchor nail in the treatment of acute Achilles tendon rupture.MethodsA retrospective research was performed on 35 cases of acute Achilles tendon rupture treated with the improved oval forceps suture-guiding method from January 2013 to October 2016. Instead of the Achillon device, we perform the Achillon technique with the use of simple oval forceps, combined with absorbable anchor nail, percutaneously to repair the acute Achilles tendon rupture.ResultsAll patients were followed up for at least 12 months (range, 12–19 months), and all the patients underwent successful repair of their acute Achilles tendon rupture using the improved oval forceps suture-guiding method without any major intra- or postoperative complications. All the patients returned to work with pre-injury levels of activity at a mean of 12.51 ± 0.76 weeks. Mean AOFAS ankle-hindfoot scores improved from 63.95 (range, 51–78) preoperatively to 98.59 (range, 91–100) at last follow-up. This was statistically significant difference (P < 0.001). Mean Achilles Tendon Total Rupture Score (ATRS) at final follow-up was 94.87 (range, 90–100).ConclusionThe improved oval forceps suture-guiding method could make the advantage of minimally invasive repair with less complications, reduced surgical time and similar functional outcomes compared with the traditional open surgery. In addition, our new technique could save the cost of surgery with the compare of the Achillon device. At the same time for the cases which the remote broken tendon ends were within 2 cm from the calcaneal nodules, because of the less tendon tissue was left in the remote side, traditional percutaneous methods are incapable to ensure the reconstruction strength. By using the anchor nail, the improved technique has better repair capacity and expands the operation indication of oval forceps method.     

Application of pre-contoured anatomic locking plate for treatment of humerus split type greater tuberosity fractures: A prospective review of 68 cases with an average follow-up of 2.5 years

ObjectivesAlthough various implants exist for 3- and 4-part proximal humerus fractures, few implants are appropriate for humerus split type greater tuberosity fractures. The goal of this study was to assess the efficacy of pre-contoured anatomic locking plate for humerus split type greater tuberosity fractures.MethodsA retrospective review of 68 patients with humerus split type greater tuberosity fractures treated with open reduction and internal fixation using anatomic locking plates between January 2014 and October 2016. Postoperatively, patient radiographs, functional results, and complications were reviewed.ResultsAll patients got a mean follow-up of 30.5 months (range 14–46 months). Average fracture healing time was 9.4 weeks (range, 8–14 weeks). Overall mean Constant score was 86.8% (range, 70%–96%). The result was rated as excellent in 25 patients (Constant score: 92.1%), good in 38 patients (Constant score: 85.3%) moderate in 5 patients (Constant score: 71.8%) and poor in 0 cases. The excellent-good rate was 92.6%. No recurrence of dislocation occurred in the 30 cases with shoulder dislocation. All fractures healed without the complications of wound infection, subacromial impingement syndrome, nonunion, secondary displacement, and implant loosening.ConclusionPre-contoured anatomic locking plate is a reliable option in treating humerus split type greater tuberosity fractures as it provides stable fixation with an early return to function. The surgical technique is easy and efficient.     

颈椎椎间融合器复合涂层及生长因子在山羊体内的融合效果评价

 目的 在活体山羊颈椎上比较自体三面皮质髂骨、帽式颈椎椎间融合器（hat type cervical intervertebral fusion cage,HCIFC）、表面喷涂羟基磷灰石的HCIFC及载有生长因子的羟基磷灰石涂层HCIFC的椎间融合效果。方法 将32头山羊随机平均分为4组：自体骨组、HCIFC组、羟基磷灰石涂层组及生长因子组。各组均行C₃~C₄椎间盘切除术并植入以上内植物。于术前、术后即刻及术后1、2、4、8、12周摄颈椎正、侧位X线片,于侧位X线片上测量平均椎间高度（disc space height,DSH）、椎间角（intervertebral angle,IVA）及前凸角（lordosis angle,LA）;术后12周处死动物,取C₃~C₄节段标本进行生物力学测定及组织学评估。结果 生长因子组的颈椎屈曲、后伸和侧屈的平均刚度显著大于其他组（P<0.05）;羟基磷灰石涂层组后伸、轴向旋转及侧屈的平均刚度显著大于HCIFC组和自体骨组（P<0.05）。影像学及组织学检测结果显示,3个颈椎椎间融合器组的椎间融合效果均好于自体骨组,其中生长因子组的融合效果最好。结论 羟基磷灰石涂层可以改善颈椎椎间融合器的融合效果,生长因子能促进骨融合。     

手术治疗桡骨远端不稳定骨折

目的：探讨切开复位钢板内固定及外固定支架治疗桡骨远端不稳定骨折的初期疗效。方法：回顾分析2005年6月—2008年12月120例经手术治疗的桡骨远端骨折患者的临床资料。120例患者中,105例采用掌侧入路掌侧钢板固定,5例用联合入路掌侧钢板固定,10例用外固定支架固定。结果：所有患者术后随访6~42个月,平均14个月。采用Dinest功能评估标准评定,优80例（66.67%）,良25例（20.83%）,优良率为87.5%。结论：桡骨远端不稳定骨折应积极采用手术治疗,应根据患者的骨折类型来选择不同的手术方式及固定方式。骨缺损时应积极植骨,促进骨愈合。     

沪滇对口帮扶医院骨折治疗模式的转变

目的以沪滇医疗对口帮扶前后云南省昌宁县人民医院治疗股骨粗隆间骨折模式的转变,分析帮扶项目提高对口医院医疗服务能力的方案。 方法回顾性分析云南省昌宁县人民医院2012年10月至2017年10月在帮扶下技术改进前后2种手术方式治疗股骨粗隆间骨折的效果,按帮扶前后2种手术方式分为帮扶前股骨近端锁定钢板固定组（钢板组）17例和帮扶后股骨近端防旋髓内钉（PFNA）内固定组（PFNA组）25例,使用t检验比较2组患者手术时间、术中出血量、开始负重时间、完全负重时间、术后1年髋关节Harris评分及住院费用等情况的差异,采用χ²检验比较2组患者术后并发症的差异。 结果42例患者术后随访12~18个月,平均14.3个月。PFNA组平均手术时间、术中出血量、开始负重时间、完全负重时间及住院费用低于钢板组［（86.80±28.97）min vs （156.76±31.70）min、（116.40±52.59）ml vs（273.53±113.85）ml、（12.50±3.72）d vs（20.19±5.98）d、（13.71±2.26）周vs（17.75±2.02）周、（14.40±1.94）千元vs（17.53±1.59）千元］,Harris评分总分高于钢板组［（91.05±4.89）分vs（80.14±8.82）分］,差异均具有统计学意义（P<0.05）。术后并发症发生率PFNA组（4/25）低于钢板组（7/17）,且差异具有统计学意义（χ²=42.000,P<0.01）。 结论医疗帮扶能改善对口医院骨折的治疗模式,提高股骨粗隆间骨折治疗效果,减少因病致残、因病致贫的发生。     

冲压机械致工业性手外伤危险因素的病例对照研究

目的：了解冲压机械所致工业性手外伤的危险因素和有事故倾向性的人群。方法采用1：2配比的病例对照研究方法，对收治的冲压机械所致急诊工业性手外伤患者及其对照人群开展可能危险因素的调查。采用SPSS软件进行单因素分析和多因素条件Logistic回归模型拟合。多因素条件Logistic回归模型拟合时采用逐步回归分析方法，将变量引入模型的显著性水平设为0.05。共有符合条件的病例94例，因各种原因而未进入调查7例，最后获得有效配对87对进入分析。结果多因素 Logistic回归分析结果显示：每日工作时间和伤前工时越长，发生工业性手外伤的危险性越大，OR值分别为1.50和1.22。使用机械安全装置和贯彻安全操作规程与否是手外伤发生的主要危险因素，其OR值分别为0.26和0.35。结论每日工作时间过长者是具有事故倾向性的人群。在完善安全防护装置和贯彻实施安全操作规程的同时，加强对该亚人群的保护，可降低冲压机械所致工业性手外伤的发生频率。     

Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics

PurposeControversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs.MethodsIn this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates.ResultsThirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98–1.18) for thirty-day mortality, 1.12 (95% CI 1.04–1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88–1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6–8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly.ConclusionsDespite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.